14 October 2010

I groaned when I read the chart. It didn't look promising, and in fact it looked downright painful. A flog -- might take a ton of work and involve a difficult disposition. And worse, I had picked it up with only a little more than an hour to go in my shift. These are the "witching hours," when there's not really enough time left to perform a work-up and dispo a patient, but when there's a long enough time left before your relief arrives that you can't in good conscience let the patient wait. I toyed with the idea of saying "hi" to the patient and getting labs ordered and seeing if I could sign it out to the next guy. Not too unreasonable if it was going to require some time-consuming test, which it looked like it might. I braced myself for the worst, squared my shoulders and walked into the room.

To my surprise, I found myself calling the admitting doctor fifteen minutes later, diagnosis in hand.

There were red flags all over the chart to begin with:

75-year old woman, speaks only Ukranian: Great. I'm going to have no capacity to communicate with this lady. Not to stereotype, but in my experience there's a strong cultural reticence among elderly eastern european women. Translators help only a little bit.

One month of fever, temp at triage 38.5: She's old and febrile, so it's going to be something real. This is not a worried well person I can blow off, reassure, and send away.

Headache: Oh shit, am I going to have to do a spinal tap on this little old lady? Jebus, let it not be so.

Seen in ER three times this week, and in clinic twice: What possible reason is there to think that I am going to figure this out when five previous doctors have not?

Yeah, there are times when ritual suicide seems a more attractive option than sticking your head into the morass, but this is the life I have chosen. I threw myself into it. The scene in the room was verging on the comical. This stout, wizened old woman could have been the embodiment of Mother Russia herself, so classic was her broad, deeply lined face. She lay back on the gurney, her head wrapped in a white babushka and a floral scarf around her shoulders. She was wearing a pair of oversized wrap-around sunglasses similar to the cheesy old Blu-blockers. For some reason her family had carefully wrapped a couble of ER blankets around her head and her lower body, so she looked as if she were partially mummified. She was attended by two very concerned, ridiculously attractive younger Russian women.

As I had anticipated, the old lady said not a word for herself. Her daughter and granddaughter did all the talking, and when I tried to address questions directly to the patient, the old lady gave monosyllabic replies, which her family amplified on translation to full paragraphs. The story was both reassuring and alarming. She had already had CT scans, spinal tap and blood work on more than one occasion, with no diagnosis. So at least I was unlikely to have to repeat the tap, I reflected. But she also had now lost the vision in her left eye, and the right eye was very blurry. The daughters were also concerned about the new swelling of her eyelids and face.

Indeed, I noticed that there was a significant amount of periorbital edema, bilaterally, and also some faint erythema. I wondered whether the vision loss was from the eyelids being swollen shut, maybe a facial cellulitis, or possibly even a retrobulbar cellulitis could cause fever and vision loss. I mused on these possibilities as I went to examine her.

She flinched violently away from me as I touched her face to remove the sunglasses. So it was very tender. I wanted to examine a bit more thoroughly, so I moved to push her babushka back. This provoked quite a reaction! She slapped my hands away and unleashed a rapid diatribe in Ukranian. I didn't understand a word of it, but the meaning was quite clear: she did not want me to touch her babushka!

I was firm, however, and she submitted to my requests (with some coaxing from her daughters), and when I peeled off the head-blankets and afore-mentioned babushka, I was struck by these two large, bright red swollen lines running up the sides of her temples. Right ... along ... the course ... of the ... (wait for it) ... temporal artery! It was the most amazing thing I have ever seen, and quite tender, as well. I immediately went back to the computer and checked her previous labs -- sure enough, her sed rate was 75. Somehow, one of the previous five docs had ordered the right test and managed not to put two and two together. Maybe the patient didn't let him touch her babushka!

Not to be critical, of course. This was not an easy history or exam, and it was probably way more obvious by the time I saw it. (Her sed rate was over 140 by that time, so there really had been progression of disease.) And Temporal Arteritis is ridiculously rare -- I've been doing this for well over a decade and I have never actually seen it before. I can't vouch for the fact I would have figured it out on the first visit. But it wound up being enormously satisfying: I got this "red flag case" admitted and started on IV steroids, with an optho consult, all in a little over half an hour. And I got to feel, perhaps undeservedly, terrifically clever for being the guy that figured it out, or at least being the guy who removed the babushka. Sadly, this may not make much of a difference for this lady -- the visual loss is often permanent. It's also the exception that proves the rule: I wrote recently about the general uselessness of the physical exam. This is one of those cases where exam was everything, and why you still have to do it.

Also, I just love saying "babushka." That word has got such a lovely round feel to it: baBOOOshka. Babuska. Babushka. I'm really a simple man with simple pleasures.

(Also, I know that Ukranians and Russians are not the same thing, just like Irish and Scots aren't, and they hate being conflated together. Permit me my rhetorical flourishes.)

7 comments:

I once had a patient who told me he had temporal "arther-itis" which, per him, meant that his "skull bones on the side of [his] head had some arther-itis in them like [his] knees" and that he took steroids and got better.

Most GCA has a normal physical exam. The diagnosis should typically be made on history with confirmation by a biopsy although even a negative biopsy doesn't rule it out if a history of new HA, scalp tenderness, jaw claudication, visual changed +/- B symptoms. This should be on the differential if any one over 50 with new HA or fever.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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